Fastbleep Ltd Image/Video Consent Form Consent for the publication of images/video of them by Fastbleep Ltd.

To be completed by the corresponding author: Subject matter of picture, photo or video (the “material”):

Name of originator:

Address of originator:

Title of material:

To be completed by the subject: I give my consent for this material to appear on fastbleep.com and associated publications. I have seen any pictures, photographs and videos and read the material to be published. I understand that:

The material may be placed on Fastbleep Ltd’s website (fastbleep.com). The website’s intended audience is healthcare professions students, applicants to healthcare courses and healthcare educators though it may be freely accessed by others;

The material may also be used in full or in part in other publication and products published by Fastbleep Ltd. This includes publication in English and in translation, in print, in electronic formats, and in any other formats that may be used by Fastbleep Ltd now and in the future.

The material may be used for advertising or packaging, but only in relation to Fastbleep projects;

The material will not be used out of context;

This consent form will be retained by the originator, and a copy sent to Fastbleep Ltd.

I can revoke my consent at any time before publication, and without giving a reason. Once the material has been committed to publication, it will not be possible to revoke the consent.

I consent for photographs of me participating in a ‘Fastbleep Foundation’ session to be published: (please print YES or NO): ________

Name of subject

Signed: Date: